Multimodal Stepwise Approach to Reducing In-Hospital Opioid Use After Cesarean Delivery: A Quality Improvement Initiative

• Published in: Obstetrics and gynecology (New York. 1953) Vol. 133; no. 4; pp. 700 - 706
• Main Authors: Smith, Alisha M., Young, Paul, Blosser, Colleen C., Poole, Aaron T.
• Format: Journal Article
• Language: English
• Published: United States Lippincott Williams & Wilkins 01-04-2019; by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved
• Subjects: Acetaminophen - therapeutic use; Adult; Analgesics, Non-Narcotic - therapeutic use; Analgesics, Opioid - therapeutic use; Cesarean Section - adverse effects; Cesarean Section - methods; Cohort Studies; Female; Hospitals; Humans; Pain Management - methods; Pain Management - statistics & numerical data; Pregnancy; Quality Improvement; Retrospective Studies
• ISSN: 0029-7844; 1873-233X
• DOI: 10.1097/AOG.0000000000003156

OBJECTIVE:To evaluate the association of a standardized, structured approach to in-hospital postcesarean delivery pain management with maternal opioid use after cesarean delivery.
METHODS:We conducted a retrospective cohort study of women who underwent cesarean delivery before and after a quality improvement intervention at a single tertiary care center. A multidisciplinary task force revised electronic order sets for all patients who underwent cesarean delivery with neuraxial anesthesia. The revised order set separated acetaminophen from opioids, scheduled acetaminophen and nonsteroidal antiinflammatory drug administration, and limited opioid use to breakthrough pain. Data were collected by electronic chart review. The primary outcome was median morphine milligram equivalents per hospital stay. Secondary outcomes included median morphine milligram equivalents per day, median pain scores, time to discharge, and opioid–nonopioid pain medication use. Descriptive and bivariable analyses were performed.
RESULTS:There were no significant differences in baseline characteristics in the preintervention (n=283) and postintervention (n=286) groups. There was a 75% reduction in median morphine milligram equivalents per stay from 120 (90–176 interquartile range) preintervention to 30 (5–68) postintervention (P<.001) and a 77% reduction in median morphine milligram equivalents per day (51 [41–60] vs 12 [2–25], P<.001). There was no difference between groups in time to discharge or median pain scores. There was no difference in ketorolac use (80% preintervention vs 75% postintervention, P=.14) or in median ibuprofen mg per day (1,391 preintervention vs 1,347 postintervention, P=.22). There was an increase in median acetaminophen mg per day (753 preintervention vs 2,340 postintervention, P<.001). There was a significant increase in patients who used no opioids during their hospital stay (6% preintervention vs 19% postintervention, P<.001).
CONCLUSION:A multimodal stepwise approach to postcesarean delivery pain control was associated with markedly reduced opioid consumption without increasing hospital stay or median pain scores. By separating acetaminophen from opioids and limiting opioids to breakthrough pain, we were able to operationalize a tier-based approach to pain management.